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search designs (“Does treating IDUs result in control of infection?”) exhaust the demands for appropriateness in the decision about whether to treat IDUs?
When we adopt the human rights perspec-tive, the answer is no, because otherwise we will be violating a set of rules that our civilizing ex-perience identifies as fundamental for good hu-man life. What the huhu-man rights treaties and conventions express as a formal imperative – everyone is born and dies with equal rights to health, which requires our societies to provide treatment for all – in fact is the crystallized, in-stitutionalized experience of an “appropriate-ness” that has reached an extremely high degree of consensus. Therefore, we must treat IDUs.
Still, is the degree of association between drug injecting and treatment difficulties a kind of unnecessary information? Certainly not. On the contrary, this is essential information if we are really concerned about having effective treatment for everyone who needs it. Still, it will only be effective in fact if the scientific studies do not dwell exclusively on detecting and de-scribing the risk and measuring the association. If we focus exclusively there, the only advantage we derive from the correctness of such knowl-edge is the following question: who will we treat, and who will we not treat, or can we decide to treat everyone, even though such a practice is “incorrect”? However, if based on the identifica-tion of this associaidentifica-tion, we derive the quesidentifica-tions of “how?” and “why?”, if we seek to understand what this association means (having the human community as our references) and the specific difficulties identified among IDUs, will we not be in a better position to answer the practical questions about how to treat IDUs, rather than simply having to decide between treating or not treating? Will it not be indispensable for us to develop vulnerability studies, in addition to risk studies, in order to guarantee IDUs the human right to be less exposed to HIV and less suscep-tible to developing and dying from AIDS?
A relevant spin-off of the reading of Vlahov & Celentano, beyond the above-mentioned sci-entific correctness of beliefs on treatment for IDUs, is thus the reinforced conviction that good practice in the field of prevention and care in HIV/AIDS requires both a clear norma-tive horizon for judgments on appropriate ac-tions and strategies and a set of comprehensive and interpretative investigations on the associ-ations. In other words, the vulnerability of giv-en population groups, grasped by means of ref-erence to their situation vis-à-vis rights, re-mains on the order of the day and can provide practical elements in order to establish
con-crete responses to the need identified by the authors to overcome the medical community’s stigma and discrimination towards IDUs, in or-der for effective treatment to take place.
The authors reply
Os autores respondem
David Vlahov & David D. Celentano
We appreciate the opportunity to offer our per-spectives on the management of HIV infection in drug users, and to respond to the views of the multiple distinguished contributors reviewing our essay. Rather than address each separately, we summarize some themes across the contrib-utors and offer our reflections.
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ing populations to receive HAART. This cate-gorical treatment of drug users ignores variabil-ity and institutionalizes discriminatory policies. With respect to HIV care, the ability to predict those who can benefit most from therapy is poor-ly appreciated. Our earpoor-ly study noted that the in-creased survival benefit of HAART in drug users was dramatic; it held regardless of whether a per-son was a current or former user, had high or low frequency of use, or type of drug used (primarily cocaine and heroin). The survival benefit of HAART in this population was comparable to other populations. While adherence was not re-ported in this study (which is somewhat irrele-vant given the dramatic survival improvements), this is an important issue in discussions of treat-ment eligibility. Clinicians are expected to make treatment decisions, but clinical decision-mak-ing is imperfect; several studies compardecision-mak-ing physi-cian prediction of adherence and documented patient adherence have shown low correlations. Thus, some drug users can benefit from treat-ment, but individual and provider factors that predict treatment success are imperfectly under-stood. Categorical exclusion of drug users from treatment ignores variability within (and be-tween) groups and ultimately denies hope.
Another theme raised in the commentaries relates to tradeoffs between benefits and risks of medical therapy for HIV infection. HAART pro-vides clinical improvement, and many clini-cians report that this increased survivorship is accompanied by improved quality of life. Like-wise, much has been made about the public health value of the reduction in HIV viral load that can result from HAART, which may reduce risk of inadvertent transmission to others. How-ever, several questions remain: improved re-sponse may lead to beliefs of non-transmissibili-ty and therefore relapse to higher-risk behaviors. As noted in the commentaries, this problem is not limited to drug users; in fact it has been re-ported in studies of women and men who have sex with men. While the concern is real, a recent meta-analysis concluded that the overall prob-lem was relatively minor. This is not to minimize the potential, but as the contributors comment-ed, this is not a basis for exclusion but a call for education. Likewise, another concern is that HAART is associated with toxicities and side ef-fects that could impair adherence and contribute to development of resistance. However, this problem is not limited to drug users; rather than excluding patients, it requires clinical monitor-ing and the medical art of therapeutic titration. Another theme raised was primary preven-tion. While the case was made that the literature argues for drug abuse treatment to remove users
from infection risks (by not using needles, or not using drugs), the availability of drug abuse treat-ment is uneven. In the U.S., data noted that only one half of users had ever been in drug abuse treatment, and at any given time the proportion in treatment was about twenty percent. Multi-ple courses of treatment are generally necessary before abstinence occurs, with the user remain-ing at risk between treatment episodes. Thus, drug treatment can be beneficial to an individ-ual, but the public health impact is diminished by lack of widespread availability of high-quality treatment. Thus, we need additional, comple-mentary strategies for primary prevention meth-ods, including outreach education and wider access to sterile syringes’ HIV prevention com-ponents that were already viewed as scientifical-ly valid by the U.S. Secretary of Health and Hu-man Services nearly eight years ago.
